Provider Demographics
NPI:1043601164
Name:SONG, LI (NP)
Entity type:Individual
Prefix:
First Name:LI
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 PONTIAC LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1261
Mailing Address - Country:US
Mailing Address - Phone:248-742-1638
Mailing Address - Fax:248-742-1654
Practice Address - Street 1:4206 PONTIAC LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-1261
Practice Address - Country:US
Practice Address - Phone:248-742-1638
Practice Address - Fax:248-742-1654
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704261932208VP0014X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily